Miliary TB

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Miliary TB
2
History

• 29 y Female Ethiopian
• Admitted To Medicine with
• 1/52 Fever , night sweating , diarrhea
• No contact with similar case
• No cough , SOB , Chest pain

3
History

• Diarrhea non bloody 2-3 /day
• No jaundice , upper or lower GI bleeding
• No dysphagia , odynophagia
• No recent travel
• Pre immigration exam ? N

4
History

• PMH -ve
• No medication
• Non smoker No ETOH
• SR decrease hearing tinnitus

5
Examination

• Febrile 38.5 BP 110/65
• HR 95 RR 18 Sat 95
• No lymphadenopathy , clubbing
• Chest clear , good breath sound
• CVS S1S20
• Abd Mild diffuse tenderness
• No guarding , rigidity or rebound

6
Investigation

• CBC WBC 5 Lymph .3
• Hb 65 MCV 69 RDW 16
• Plt 85 PTT INR N
• Na 133 K 3.2 Co2 16
• Creat BUN N
• AST 160 , ALT 140
• Alk Phos 60 Billirubin N

7
Hospital Course

• Admitted to H4
• for Hydration work up
• CT Abdomen
• Multiple LN paraaortic , celiac
• Multiple nodules in spleen
• Thickening in small bowel ascending colon
• ?CT guided Bx was planned

8
Hospital Course

• Chest Medicine was consulted
• Increased SOB O2 requirement
• O/E febrile 39.5 BP 100/55 HR 140
• RR 22 Sat 93 on 7 l O2
• Chest Bilateral coarse crackles
• CVS S1S20 II /VI ESM LSB
• JVP 3 cm ASA

9
Hospital Course

• CBC Hb 65 CD4 25
• ABG PH 7.38 PAO2 90
• PCO2 30 Hco3 20
• Blood ,sputum C/S ve
• Empiric Abx for ? Pneumonia
• Cefotaxime azithromycine

10
Hospital Course

• Anti TB Rx Septra was started empirically
• BAL ? cytology , gram stain -ve
• ve AFB
• CT guided LN Bx ?necrotizing granuloma
• HIV ve

11
Hospital Course

• Clinical improvement within few days
• Worsening elevation liver enzyme
• drop in Hb
• No evidence of hemolysis
• Required PRBC Tx

12
Hospital Course

• Liver Bx ?non specific hepatitis
• ? Drug reaction Vs
  infectious
• Anti Tb Rx modified to INH , Rifabutin
• Gatifluxacin
  ETB
• Discharged with plan to start HAART Rx after
  treating TB

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Miliary Tuberculosis

• Used to be pathological then radiological term
• 1700 by John Jacobus Manget ?nodular surface of
  that look like Millet seeds
• Currently used denote all forms of progressive,
  widely disseminated hematogenous TB, even if the
  classical pathologic or radiologic findings are
  absent.
• 20 ot TB cases diagnosed postmortem in the pre
  antimicrobial era were miliary ?fallen to 0.7
  after

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Miliary Tuberculosis

• Variable presentations ? from non specific
  symptoms to septic shock ARDS
• Most common pulmonary manifestations
• ?SOB,cough ,chest pain ,crackles
• hypoxemia
• Most common general symptoms
• ?fever ,wt loss , night sweating malaise

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Miliary Tuberculosis

• Delayed missed diagnosis is usually due to
• Non specific symptoms
• Lack of suspicion
• Delay in culturing all accessible body fluid
• Can arise ? progressive primary infection
• ?reactivation of a latent focus with spread
• ? rarely via iatrogenic origin.

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Miliary Tuberculosis

• Progressive primary disease
• After a local focus is established in the lung
• ? lymphatic then hematogenous dissemination
• with a predilection for spread to the most
  
• vascular organs, such as the liver, spleen,
  
• bone marrow and brain

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Miliary Tuberculosis

• Progressive primary disease
• Occurs when these distant foci fail to heal and
  is typically seen within the first six months
  after primary infection
• Many patients have underlying medical conditions
  impairing the development of effective cell
  mediated immunity

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Miliary Tuberculosis

• Reactivation of a latent focus
• Reactivation of latent focus of infection with
  ?subsequent erosion into adjoining
• lymphatics or blood vessels
• Commonly occurs years or decades after primary
  infection

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Miliary Tuberculosis

• Radiological Investigation
• CXR ?faint reticulonodular infiltrate
• Pleural reactions
•  Hilar or mediastinal adenopath
• CT ?multiple small nodules
• septal thickening
• non specific